Dialogue Volume 14 Issue 2 2018 - Page 86

Council Member Candidate Nomination Form Candidate Consent – Please print or type: DEADLINES FOR COMPLETED FORMS I consent to allow my name to stand for election for Council Member. Forms must be received by the College by 4:00 p.m. Tuesday, August 21, 2018. *Forms can be sent by fax, email or mail. Name:___________________ ___________________________­­­­­­­­­­­­­ District #:___________ CPSO Number:___________ SEND THE COMPLETED FORM TO: Signature:­­­­­­­­­­­______________________________________________________________ CPSO Council Nomination – Att: V. Clarke College of Physicians and Surgeons of Ontario 80 College Street Toronto, ON M5G 2E2 Home Tel.:______________________________ Business Tel.: _____________________ Street Address:__________________________________________________________ ______________________________________________________________________ City/Province/Postal Code:­­­­­­­­­­­­­­­­­­­­­­­­­­_________________________________________________ Fax: Vanessa Clarke at (416) 967-2644 Email: councilelections@cpso.on.ca PLEASE NOTE: To stand for election, you must be nominated by five members of the College who are: eligible to vote in the district in which you are being nominated; not in default of payment of fees owed to the College; and who have a license that is not under suspension or revoked. We recommend that seven nominators be provided in the event that a nominator does not meet these criteria. NOMINATION We the undersigned members who meet the eligibility criteria referred to above, nominate the above-named candidate for election: 86 Print Name Signature CPSO Number 1. ____________________________________ ______________________________________ ________________________ 2. ____________________________________ ______________________________________ ________________________ 3. ____________________________________ ______________________________________ ________________________ 4. ____________________________________ ______________________________________ ________________________ 5. ____________________________________ ______________________________________ ________________________ 6. ____________________________________ ______________________________________ ________________________ 7. ____________________________________ ______________________________________ ________________________ DIALOGUE ISSUE 2, 2018